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tv   Pharmaceutical Executives Testify on Rising Insulin Costs  CSPAN  April 16, 2019 1:28pm-4:21pm EDT

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>> once, tv was simply three giant networks and a government supported service called pbs. then in 1979 a small network with an unusual name rolled out the big idea.let viewers decide on their own what was important to them. c-span opened the doors to washington policymaking for all, bringing you unfiltered content from congress and beyond . in the age of power to the people, this was true people power. in the 40 years since, the landscape has changed. there's no monolithic media, broadcasting has given way to narrowcasting, youtube stars are anything but c-span's big idea is more relevant now than ever. no government money supports c-span, if nonpartisan coverage is funded by your cable or satellite provider. on television and online, c-span is your unfiltered view of government so you can make up your own mind . >> drugmakers explain why
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insulin prices are going up, members questioned executives from eli lilly and other pharmaceutical companies as well as drug stores like cvs . diana get chairs the subcommittee. >> the subcommittee on oversight and investigation hearing will now come to order. today the subcommittee on oversight and investigations is holding a hearing entitled price of a life-saving drug, getting answers on the rising price of insulin, this is the second part of the hearing examining insulin affordability and the ensuing health colleges that affect some patient lives. the chair recognizes herself for the purposes of an opening statement. for 7 and a half million americans relying on insulin, addressing today has affected countless lives. that's why this committee is determined to find answers and to find solutions and the committee is well aware despite the fact that insulin has s been around for almost 100 years, it has become outrageously expensive.
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for instance, the price of insulin has doubled since 2012 after nearly tripling in the past 10 years. we've all heard stories of what happens when patients can't afford their insulin. people have to forgo paying their bill or ration their doses or skip doses altogether. i had a listening session in my district a couple weeks ago and there was a woman who came named sierra, sierra has been struggling for over a year and a half to pay for her insulin. even after rationing or insulin, she's still paying over $700 a month . it's doubly unacceptable that anyone in this country cannot access the very drugs their lives depend on all because of the price of insulin has gotten out of control. as the cochair of the congressional diabetes caucus, this issue is personal with me. along with cochair
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congressman tom reed, we examined these issues last year and issued a report exposing some of the underlying problems in the insulin market. we put that report into the record at last month's hearing and what we found during our investigation was a system with perverse payment incentives and a lack of transparency in pricing. then last week as i said, the subcommittee held its first hearing on this issue in the new congress. we heard testimony from expert witnesses and patients in the diabetes space and their message was clear. insulin is unequivocally a life-saving drug but because of a convoluted system, it has become more and more expensive to the point where refar too many can no longer afford it, even though their very lives depend on it. we heard from gail dufour who is a native of my hometown of denver colorado lives with type i diabetes.
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she said to the committee how her price of insulin has shot up and she's had to ration her doses against the advice of her doctor. we heard from doctor alvin powers on behalf of the endocrine society who testified quote, it is difficult to understand how a drug that has remained unchanged for almost 2 decades continues to skyrocket in price. the subcommittee received testimony last week from doctor william chris to follow on behalf of the american diabetes association. he spoke about the national survey the ada conducted which found that over a quarter of the people they contacted had to make changes co to their anpurchase of insulin due to cost and those people had higher rates of adverse health effects. the witnesses had many different stories about the effects of rising insulin prices one consistency that emerged was the system is convoluted, opaque and no longer serves the patient's best interests.
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the witnesses were some of the leading experts on diabetes care and yet they couldn't point to a reasonable explanation for why these prices have gotten so high and that's what leads us here today. we have representatives from the three drug companies that manufacture insulin as well as three of the largest pharmacy benefit managers or pbm's. together these companies are the ones that produce this drug, negotiate its price and make decisions that have consequences or its availability for millions of americans. i want to thank all the representatives for coming today. i know for some of you, you had to change schedules, you had to make adjustments and i appreciate it because all of your companies play a large role in the supply chain of a critical drug and all the companies you know received a lot of criticism but we're not interested in just anger pointing or passing the buck. we're interested in finding a
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solution to this problem and that's why we put everybody here together in one panel so you can help us identify what the problem is and how we can fix it. and again, it's not my intention, i think mister guthrie agrees, it's not our intention to unjustly assign blame to one player. instead what i think is that many entities share the blame for a system that has grown up and we need a frank discussion about what's causing the increases and what we can do to bring them under control. as miss the borax testified, the release we need is right now, not next week, not next year. we need answers today because the price of insulin as risen too far and too many people are suffering and even risking death. thank you for being here ny today, i urge you to be candid and forthcoming and i'm now please recognize the ranking member mister guthrie for five minutes for purposes of an open.
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>> thank you for bringing this hearing together and i due to the remarks that you just made. last week we held a hearing on the rising cost of insulin and heard from patients, doctors and patient e groups about the rising cost of insulin has affected americans with diabetes, more than 30 million individuals have 9.4 percent of the population in the united states diabetes and in 2016 6.7 million americans age 18 and older use insulin. insulin prescribed today is different than that hundred years ago and the life expectancy of diabetics has improved dramatically. these innovations should not be underestimated. ofand a lot of exciting research is onthe horizon . they soon i hope we will have a cure for diabetes. as we discussed last week however, the average list price of insulin nearly tripled between 2002 and 2013. making this vital drawing unaffordable or too many americans. many argue that while list prices have been increasing,
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and prices have stayed relatively the same or have even gone down. this sounds great because in theory no one is supposed to pay the list price for insulin, however if a patient is uninsured or underinsured, they may end up paying the list price or close to it. we've heard more americans are paying the list price at the pharmacy counter or part of the year because of enrollment in high deductible health plans asincrease . we have struggled to fully understand and i want to emphasize this, understand while list prices for medicines have continued to rise, the prescription drug supply chain is complex and lacks transparency. we've had conversations with participants in the drug supply chain over the last two years to betterunderstand how the pricing and rebating system works . we've been told manufactures a spice and lowering the cost of drugs is as simple as manufacturers lowering the list prices. on the other hand, we've heard that manufacturers can't simply lower their list price because the pharmacy
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benefit managers or pbm's demand larger rebates and the manufacturers do not provide them, the pbm's will put their drugs on the formulary. although they're not on the panel today we've heard concerns about other entities and supply chains such as health insurance companies and as chair degette said, we want to try to get to a solution and while some may think one party in the supply chain is solely responsible to the rising price of drugs, there are incentives to increase list prices drop the drug supply chain . beyond the potential for manufacturers to make more money, a higher list price allows manufacturers to provide higher rebates, most of whom have contracts allow them to keep a percentage of the list price or receive these based on the list price. the health insurance companies decide whether to pass the rebate to their patients at the point-of-sale or keep the rebate to lower premiums across the board for all beneficiaries. the system contains many
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incentives for list prices to increase rather than decrease, unfortunately while we keep hearing assurances prices are staying flat or decreasing, almost all rebates are passed on to the health plan, we know many patients are being disadvantaged by the system and are paying more. your companies have taken steps to try to reduce out-of-pocket expenses for insulin to the patient's need them and that is a good thing. i worry however that these are only short-term solutions . it is important that we collectively find a permanent solution and improves access to and affordability of medicine such as insulin. i how witnesses for being here and i'll yield the remainder of my time to my friend from indiana. >> thank you ranking member guthrie and thank you to the subcommittee chairwoman for hosting this hearing, holding this hearing, continuing the work that was started last congress in examining the impact that rising cost of insulin has on patients
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struggling to afford this drug. nearly 700,000 hoosiers have diabetes or prediabetes is wiser as my chair of the congressional diabetes caucus founded by diana to get and tom reed. we always work in a bipartisan manner and that caucus and i hope we continue in that spirit today to find solutions. one of the companies here today, eli lilly has been headquartered in indianapolis for more than 100 years. employ thousands of hard-working hoosiers, many of whom are my constituents and while i know that lilyhas put in place programs to subsidize the cost of insulin ri and i've read all your written testimony , everyone has ideas and everyone has recommendations and that's what we need to get to today. so i look forward to hearing from our witnesses on the recommendation or change so that no american have to do without insulin or take less insulin and what they must have to stay alive and remain healthy and ithank you all for being here, i feel the back . >>.
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>> we are waiting for the chair of the full committee and ranking member for their opening statements, just wait one moment . >> the witness recognizes the ranking member of the full committee for five minutes. >> thank you madame chair and i appreciate your indulgence, , i know we're all coming back from votes so i'm glad you're having this urine today, it's important. last week we heard a lot of different opinions on why the list price of insulin as increase over the last decade, one of the doctors on the panel, she believed i
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list prices primarily benefit pharmaceutical companies. now, another doctor argued because the rebate system encourages i was prices and that the listprices increase, intermediaries in the supply chain benefit. they are used to solution is not easy as manufacturers lowering their list price, it requires water reform across the supply chain . all of the witnesses last week agreed the current pricing system for insulin is actually harming many patients as they make healthcare decisions. we heard stories of individuals rationing their insulin and forgoing other necessities ends meet. and how this can lead to serious short and long-term health problems and hospitalizations which i'm sure you all understand. critical we work towards ensuring that all direct have access to insulin. to do so we need to identify and break through barriers and challenge brings back the cost of insulin for patients. for more than two years we've been examining the various
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drivers and increase healthcare costs so i'm glad that effort is continuing today. earlier this year as part of this work myself and republican readers sent a letter to each of you that asked specific questions about the cost of insulin and the barriers to competition in the insulin market. we wanted to learn more about what's going on. i want to thank each of you are your thorough responses to our questions and most helpful as we work on this issue. while the discussion centered around the cost and barriers that exist reducing cost is important we do not forget the critical role that both of you, the drug manufacturers and pharmacy benefit managers, pbm's have been making sure patients have access to life-saving medicine such as insulin area and the insulin available for diabetics would not exist without significant investment from eli lilly, novo nordisk and sanofi have made to improve these medicines. these investments to save the lives of diabetics, manufacturers. patient assistance programs to help patients access to
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affordable insulin.while there will be questions about whether the changes in insulin over the past two decades justify how much the price for insulin, list price has increased over the same period, we know the manufacturers rarely receive the list price for their medicine. likewise, pbm's provide many important services to patients and use different tools to help control costs while promoting healthcare. for example in addition to numerous other programs, eds rated track transformed diabetes program they y received several cost-containment strategies to help reduce savings up to our ask rated tool to provide greater visibility and clinically equivalent alternative medicines at the point of prescribing. just last week express scripts announced a new patient assurance program that will ensure eligible people participating in express reps plan pay no more than $25 for a 30 day supply of insulin.
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and while these programs for manufacturers are important and useful in the short-term, they are only a band aid. we have to work on the long-term solutions, many of the ncconcerns we heard at last week's hearing are very similar to the issues that were discussed at our hearing examining the prescription drug supply chain over a year ago i appreciate hearing from the manufacturers and the pdm's today about your perspectives on why insulin costs are rising but like we li heard at the hearing on drug pricing in 2017, to fully understand why the cost is increasing for many patients, we will need to hear from the other participants in the supply chain including the distributors, health insurance plans and pharmacists llso that at the end of the day we have to put the patient, the consumer first and everything that we do so i want to thank our witnesses for responding to our questions and i want to thank you for being here today. you will contribute to our work and that is most valuable unless once the remainder of my timeand i'm sure i would yield back .
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>> the chair recognizes the chairman of the full committee mister alone for five minutes. >> today the committee is holding the second of a two-part hearing on the increasing price for insulin, millions ofamericans rely on the strong and are affected by the ever increasing prices . people having to make sacrifices to be able to pay for their insulin and some are even forced to go without sometimes with tragic consequences. the subcommittee heard from expert witnesses in diabetes care, they provided testimony about the rising price of insulin medication and the effects it's having on patients living with diabetes . we heard from ann in doctor knowledges to describe a system that makes it difficult if not impossible for him to determine how much his patients will have to pay for their insulin and we heard from patient advocates
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to describe the hardships patients indoor when they can no longer afford the medication or are forced to switch. these patients described a broken system where there's not enough transparency surrounding prices and not enough incentive to keep prices down so today we have before us the companies that make these drugs, negotiate better prices and make available through health plans. their actions and decisions have a profound effect on the lives of everyday americans and we need to hear these companies respond to the in their actions and what ek their actions are doing to contribute to rising prices or hopefully reduce prices. we know that companies need to make money to succeed and in a normal market, price would reflect what the market can bear. the problem is the market for insulin is made up of people who can't survive without the noproduct and i'm concerned the market, it appears there is a limiting competition, little incentive the prices at a level the patient can afford and perhaps incentives in
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place to keep raising prices. d as a result where left with a drug that has been available for 100 years and yet the price tripled and then doubled in the last couple decades, clearly something is not right. three companies currently manufacture insulin and they're all represented d today. they not only make the drug but also sent the list price, while most people did not end up paying the list price on insured patients often do and even insured patients can be affected when the list price rises and that's exactly what's been happening as the list price for insulin as skyrocketed in recent years and it ripples through the entire system. we also have a pharmacy benefit managers or pbm's here whose job it is to negotiate prices and there's not much transparency in these negotiations and there are questions as whether discounts are being passed on to the patients. when themanufacturers have been criticized for raising their pricing , they have often pointed the finger at the pbm and when the pbm
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seven question about their practices, they often point your finger back to the manufacturer . so we're leftwith no accountability , for the millions of people suffering in the system, these back-and-forth arguments are frustrating and frankly unacceptable. everyone seems to be coming out ahead accept the patient's and no one really should suffer because of the high price of insulin is out of reach so i hope we can all learn today about why the cost of insulin is skyrocketing and the role of manufacturers and pbm's play and figure out how to deal with it so we can keep make insulin more affordable. unless someone he wants my time. madam chair, i will yield back. >> thank you gentlemen. the chair asks unanimous consent of members written opening statements he made mapart of the record, without objection, order. i'd like to introduce our first panel of witnesses for
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today's hearing, mister mike mason was the senior vice president lily connected care and insulin global business unit, welcome. mister doug langa, executive vice president north america operations and president of novo nordisk inc., miss kathleen tregoning was the executive vice president for internal affairs for sanofi, mister thomas moriarty, executive vice president chief policy and external affairs officer and general counsel eds health, with amy bricker, senior vice president supply chain of express reps and doctor simeon utah, chief medical officer rx, welcome to all of you. i know you're all aware that the subcommittees holding an investigative hearing and when doing so the practice of taking testimony under oath. do any of you have objections to testify under oath today? let the record reflects that the witnesses have responded no. the chair then advises you under the rules of the house
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and the rules of the committee you're entitled to the company by counsel. do any of you desire to company by counsel during your testimony today? let the record reflect witnesses have responded no. please raise your right hand so you may be sworn in. >> you swear that the testimony are about to give is the truth, the whole truth and nothing but the truth? >> you may be seated. let the record reflect the witnesses have responded affirmatively. you're now under oath and subject to the penalties forth in title 18 section 1001 of the united states code. and now the chair will recognize our witnesses for five-minute summary of their written statements. in front of each of you is a microphone and a series of lights, the light will turn yellow when you have a minute left and read to indicate your time has come to an end. i would appreciate it if you try to keep your opening statement within the timeframe because we want to
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make sure that all of the members have the opportunity to ask their questions today. so we'll start with you mister mason, you are recognized five minutes for purposes of an opening statements. >> chairwoman, ranking member guthrie, chairmanpallone, ranking member wallin , my name is mike nation senior vice president of connected care and insulin eli lilly. thank you for theopportunity to participate . thanks as well as your staff who met with us. i'm pleased to be here to continue thatconversation. eli lily was founded in 1876 and today employs over 16,000 people in the united states . we are headquartered in indianapolis and are proud to have announced the birth insulin product in 1923. for a century we committed to helping people with diabetes with better and longer lives, we've invested billions in the discovery of new treatments including biotech insulin , humalog and phaser
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ending 2018 we inannounced our commitment to our research and development partnership that could eliminate the need for insulin. eli lilly is developing connected devices that we hope will help people improve outcomes in adherence. like many people who work at lily, i have a personal connection to the issues we discussed today. four of my immediate family members live with diabetes. i've seen them: with the daily burdens of the disease including injections before each mill. i've seen the devastating publications of diabetes in their lives. and i know y firsthand that may benefit from new innovative treatment. often our phone calls and visits turned to their diabetes. over the years we focus on these conversations on how they were managing their diabetes area but within the last two or three years conversations have changed. we now spend more and more time talking about how much
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they pay out-of-pocket for insulin. as a leader lily it's ondifficult for me to hear anyone in diabetes community worry about the cost of insulin. to many people today don't ny have affordable access to chronic medications . my colleagues and i have reflected on how we got here and what we can do to solve this problem in the short-term and long-term. for starters we have not increased the list price for insulin since 2017. but we recognize that the issue is more complex and it's important to focus on what people pay out-of-pocket for insulin. most people who need insulin at either private or government insurance. that requires them to pay a low affordable co-pay. but some people don't benefit from these co-pays because there out-of-pocket costs are based on so-called retail or list price, not negotiated prices or co-pays. the people most exposed in our current system are those
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in the deductible page of high deductible health plans, those in the care part d average plans and individuals without insurance. we know long-term solutions are necessary but we are not waiting to address the gaps in the short-term. the lily diabetes solution center connects individuals to a suite of affordability solutions including any access to savings offers for the uninsured and privately insured with no paperwork or applications. we provide automatic discounts at the pharmacy counter the cost of prescription for lily insulin $95 for those and deductible deductible phase. we recently announced the upcoming launch of a half-price version of humalog called insulin like growth, with these and other meaningful solutions, we tried to build a safety net preventing anyone from having to pay retail price or their insulin. our solutions are working to reduce out-of-pocket costs,
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today 95 percent of monthly humalog prescriptions are less than $95 at the pharmacy. 90 percent or less onand $50 a month and 43 percent or zero. as insulin light launches and it added to formularies, even more people to pay less. and while these actions ease the burdens for most people in these coverage areas, they are still stopgap measures. long-term systematic l solutions are still needed. a good place to start is to consider the policy ideas suggested by cbs in their written testimony. the foster the widespread adoption of zero dollars co-pay on preventative medications like insulin. we agreed the solution would save lives and money while cutting straight to the heart of the affordability issue. also, we think this community for its bipartisan action last week on legislation including the create and a bill eliminating pay for play tactics. systematic change in our healthcare system will
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require action by all relevant stakeholders. weare ready to play a role and we are confident that a solution is possible . >> thank you mister langa, you're recognized for five minutes . >> thank you chair degette, mister buckley. i'm executive vice president of novo nordisk incorporated. for 90 years, novo nordisk has been dedicated to improving the lives of people with diabetes . we care deeply about the people who need our medicines and we are troubled knowing that for some, our products are unaffordable. for a company committed to helping people with diabetes, patience rationing insulin is simplyunacceptable . even one patient rationing insulin is one too many. we need to do more. we all need to do more. this is why i appreciate the opportunity to take part in a dialoguetoday . on the issue of affordability we hear a lot about listprice and i'll tell you that novo
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nordisk we are accountable for the list prices of our medicine . we also know that list price matters to me, particularly those in high deductible health plans and those that are uninsured.why can't we just lowered the list price and be done? in the current system, lowering list price for a meaningful release all patients. and it may jeopardize access to the majority of patients who have insurance and are more able to gather medicines for affordable co-pay. that's because list price is only part of the story. once we set the list price, the current system demands we negotiate with pbm's an insurance plan to secure a place on their formularies. formulary access is critical because it allows many patients to gather medicines throughco-pays at reasonable cost . the demand for rebates increases each and every year. in 2018, rebates, discounts and other fees accounted for $.68 of every dollar of gross sales in the us.
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as a result, prices of our insulin products have declined year over year since 2015. despite the investment we make in rebates, some patients including those with insurance and not paying list price or close to it at the pharmacy counter. as a manufacturer, novo nordisk has no control over what insurance patients pay at the pharmacy counter. this is dictated by design. in the last few years we see gnmore patients with benefit design that require them to pay i out-of-pocket costs so despite this ever-increasing rebates that we pay to our formularies, patients do not get the full benefit of those rebates at the pharmacy counter. this needs to change. it's time for people with diabetes to benefit directly from the rebates that we pay. i take the mission of the company to help people with diabetes seriously and personally. i lost my own father-in-law to this disease so i do know io
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firsthand what it does and how it affects patients and their families. when the healthcare market began to shift to a high deductible health plan and we saw more people were struggling to for the medications, we took action. back in 2016 we pledged to limitless price increases to single-digit percentages annually. we were one of the first companies in the commitments and we have honored it ever since . our pricing pledge and other programs we've had in place for years. with thegoal of reducing patients out-of-pocket costs . through our nearly 2 decades old partnership with walmart, novo nordisk high-quality human insulin is available at walmart pharmacies were less than $25 a bottle. in 2017 we partner with cds health and express scripts to expand the $25 human insulin offering tens of thousands of pharmacies nationwide. our human insulin is an fda approved safe and effective
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treatment for both-one and type ii diabetes. and it's used by about 775,000 patients today. since 2003 we have also provided free insulin to eligible individuals who are patient assistance program. 50,000 americans free insulin for this effort in 2008 alone. today a family of four making up $203,000 a year could qualify for a patient assistance program. we also offer co-pay assistance on a wide variety of insulin medicine which last year helped hundreds of thousands of patients lower what they pay for pharmacy counter. with all these valuable programs , we can't stop there. patients are telling us we need to do more and we hear them. the challenge is that the current system is broken.
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bringing relief to patients is going to require bigger, more comprehensive solutions built on cooperation between all stakeholders in the insulin supply chain. we want to be a part of those solutions. we look forward to working with all stakeholders to ensure this life-saving medicine remains available to everyone who need it. thankyou and i do look forward to answering questions today. >> thank you, you are now recognized . >> ranking member dockery and members of the subcommittee, like you for the opportunity to appear before you today to discuss issues related to pricing, affordability and patient access to insulin for the united states. i'm kathleen tregoning, president of external affairs, my goal is to have an open discussion about how thesystem works , our role in it and how it can be improved. patients are rightfully angry about rising costs for many medicines. and we all have a responsibility to address a system that is clearly failing to many people. as a mom i was heartbroken hearing the testimony before the subcommittee of other caparents who had not only endorsed s terrible challenges
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facing illness but have also struggled support the medications they or their children desperately need. my own family is the beneficiary of a breakthrough el in medicine. my husband john has h, a genetic disorder that makes the body unable to remove ldl or bad cholesterol from the blood. he inherited this commission from his father who passed away from a heart attack at40 years of age when john was 12 years old . by taking statins, watching his diet and exercising regularly, john himself had a double bypass at the age of 36. he still couldn't get his hi cholesterol under control.t then he came across drug. >> ..
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>> as his father and grandfather. i fully appreciate how important it is for science to continue to solve the medical challenges that impact so many families. i recognize that those breakthroughs are meaningless if patients are not able to access were for them. over the last 20 years, santa fe has been a leader in the advancement of new treatments to help people manage their diabetes. at the same time, we recognize the need to address the very real challenges of affordability. two years ago, we announced our progressive pricing principles. we made a pledge to keep list price increases at or below the u.s. national health expenditure projected growth rate. and we stand by this commitment. in 2018, our average aggregate list price increase in the united states was 4.6%, while the average aggregate night price, the actual price paid to santa fee, declined by 8%.
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the third consecutive year in which the amount we received across all the medicines went down. insulin is a clear example of the growing gap between listed net prices. lancet most described insulin. the night price has fallen over 30% since 2012. today, it is lower than it was in 2006. yet, since 2012, average out-of-pocket costs have risen approximately 60% for patients with commercial insurance and medicare. every actor in the system has a role to play. we take our responsibility very seriously. in addition to our pricing policy, we have developed assistance programs to help patients before their insulin including co-pay assistance for commercially insured patients, including those in high plans and free insulin for uninsured low income patients. our commitment to can patient
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affordability means that today, approximately 75% of all patients taken insulin pay less than $50 a month. but, we recognize that more needed to be done. last year, we launched a unique program that allowed individuals exposed to high retail prices to access insulins for $99 per vial. the lowest available cash price in the united states. based on feedback from patients, providers and the advocacy community. today we announce that we are expanding this program. beginning in june, uninsured patients, regardless of income level will be able to access any combination of the santa fee insolent they need for $99 per month at the pharmacy counter. this transformative and first of its kind program is the latest in a series of progressive and important steps we have taken to help patients afford the insulin they need. this does not eliminate the need
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for broader system reform. i agreed with the witnesses from last week that holistic reform system are not only needed but overdue. we also supported number number of recommendations outlined in my written testimony including many of the policies included in the congressional diabetes caucus report. thank you for the invitation. i look forward to answering your question. >> thank you so much. we recognize mr. moriarty for five minutes. >> thank you chairwoman. rankin amendment, my name is thomas, i serve as the chief policy and external affairs office in general counsel for cbs help. thank you for ways to look at making healthcare more affordable especially for those with diabetes and those were prediabetic. a real barrier to achieving good health is cost. including the price of insulin products which are too expensive for too many americans. over the last several years, list prices for insulin have
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increased nearly 50%. over the last ten years, list price of one product, lantus, rose by 184%. the primary challenge we face is unlike most other drug classes, there have been no generic alternatives available even though insulin has been on the market for more than 30 years. despite this, we have taken a number of steps to address the impact of insulin price increases. we negotiate the best possible discounts of the manufacturer's price on behalf of the employers, unions, government programs and beneficiaries that we serve. our latest 2018 data indicates that we have been able to reduce the total cost of diabetes drugs including insulin by 1.7%, despite brand inflation of that year 5.6%. importantly, patient adherence has also increased. specifically, we have replaced to high cost insulins, lantus sent to jail, with an effective
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lower cost. by making -- preferred, out-of-pocket costs decline by 9%. among patients who switch, their a1c your blood sugar levels were improved by .43. to put this into perspective, every one point improvement a1c among patients with uncontrolled diabetes is correlated with approximately $41400 of savings per year medical costs for each patient. this is a real-life example of how competition works. despite the efforts, we know this is not enough. let me share a story about a company and their experience with diabetes. this company saw the human toll on their colleagues and continue to see escalating costs. in response, the company began offering employees and their families $0 co-pays for insulin, providing coverage for diabetes medications even before the deductible was met.
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that means no out-of-pocket costs so employees are more likely to take their medications, improve their health and achieve lower costs. that company is cvs health. when something works for us we offer these solutions to our clients. we also offer tools for patients to help reduce their out-of-pocket costs and provide transparency at the doctor's office, at the pharmacy counter directly to the patient. creature mark members, when they're in the doctor's office getting a prescription, we provide doctors with real-time information about what is covered under the insurance and if there are effective lower cost alternatives available. we also provide information to patients online or on the phone. for cvs pharmacy customers, regardless of the health plan the prescription savings finder tool enables our pharmacists to work with patients to find the most affordable medications they
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need. beyond these tools, coordinated care approach diabetes is essential. we have taken the lead with the program we call transform diabetes care. it furthers our focus on providing patient care that eases the complexity of self-management, improves health and reduces overall costs. using a high touch engagement model and local points of care, clinicians are better able to sport specific member needs as their care requirements evolve. finally, despite what we have accomplished, we know more needs to be done. let's bring more effective lower cost alternatives to market faster by ending pay for delay schemes. let's foster the widespread adoption of zero co-pays on medications like insulin. recognizing if we treat these diseases effectively we can save lives and save money. let's past your proposal to reform medicare to provide additional support services to patients with diabetes to manage
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their own care. we look forward to working with you in the community to help accomplish our shared goals. thank you. >> thank you so much. now, ms. miss bricker, you are recognized for five minutes. >> chair, ranking member and members of the subcommittee, thank you for inviting me to testify at the hearing. my name is amy, senior vice president for some express script. i began my career in the computer new technique pharmacy senate. i'm not responsible for key relationships and strategic initiatives across the pharmaceutical supply chain. working directly with drug manufacturers and retail pharmacies with the objective of keeping medicine within reach for patients including those with diabetes. diabetes is of particular interest to me. i have witnessed the impacts personally. my younger brother, jeff was diagnosed with type one diabetes as a child. diabetes is a life-changing
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diagnosis and can have devastating effects if not managed properly. i am passionate about ensuring patients have access to the medication they need. today i will provide an overview of express scripts innovative approach to reduce the cost and increase count will be of care for people with diabetes more than 80 million americans we serve. we negotiate lower drug prices with drug companies on behalf of our clients. generating savings returned to patients for lower premiums and reduced out-of-pocket costs. additional savings are provided in our clinical support services which enable individuals to lead healthier, more productive lives. when it comes to prescription drugs our goal the best clinical outcome at the lowest possible cost. we offer innovative programs to help achieve that goal including programs that address the cost of insulin for patients. one example, are diabetes clear drink care program manages
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through a holistic approach through clinical care, analytics, and personal engagement. it offers remote monitoring source specialist team can intervene in patient blood sugars are dangerously high or low. this resulted in a 19% reduction in drug spending for diabetes. we launched insider acts. a cash discount program for patients who are either uninsured or faced with high coinsurance. partnering with drug manufacturers to provide rebates at the point-of-sale resulting in average discounts of 47% for brand drugs including an average of $150 in savings per insulin prescription. our natural preferred flex provides employers and health plans the flexibility to add drugs to their formulary if a drug manufacturer chooses to offer a lower-priced version of a drug. recently, eli lilly announced it
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is reducing the price of its humalog insulin by 50%. we are excited about their decision to lower the list price and encourage other manufacturers to do the same. most recently, express scripts announced the patient insurance program that caps the out-of-pocket costs at $25 for 30 day supply of insulin. we did this in collaboration with the manufacturers here today. we remain committed to delivering personalized care to patients with diabetes and creating affordable access to their medication. express scripts welcomes lower list prices. however list prices are exclusively controlled by manufacturers. in the absence of lower list prices negotiated rebates have become important as the drug pricing strategy. in today's system rebates are used to reduce healthcare costs for consumers. employers use the value of the discount to keep benefit premiums affordable on offer
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workplace wellness programs among other focus health initiatives. half of the clients received 100% of rebates negotiated on their behalf. in total, 95% of rebates, discounts and price reductions received by express scripts a return to employers, plan sponsors and consumers. our 2018 drug report showed a decrease in spending for diabetes medication for plans enrolled in our clinical solutions. for insulin the same plans are 1.5% decline in unit costs. express scripts achieve this result by driving competition among manufacturers while leveraging pharmacy discounts to drive savings. we can to the future we support efforts by congress and the administration to use market-based solutions that put downward pressure on prescription drug prices through competition, consumer choice and open and responsible drug
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pricing. in closing, we are proud of what we have done today. we look forward to working with the community to improve the affordability of insulin products. thank you. >> thank you. doctor -- you are not recognized. >> chair, ranking monitor, chairman, ranking member, and members of the subcommittee, good morning. i am achieve medical officer at optima and rx, a company whose dedicated employees ensure the people we serve have affordable access to the drugs they need. i'm honored to be here to discuss steps we can all take to reduce the cost of insulin. the team includes 5000 pharmacists and pharmacy technicians who help patients learn how to take their medications, avoid harmful drug interactions, manage their
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chronic conditions. our nurses infuse life-saving drugs and patient's homes. our efforts help lower overprescribing and opioids. her diabetes management program offers personalized patient driven services to high-risk members to to help them manage their diabetes. optimum rx negotiated discounts and clinical tools are reducing annual drug costs on average by $1600 per person for our customers. our efforts start with the clinical assessment by a pharmacy and therapeutics committee comprised of independent physicians and pharmacists. they evaluate our formularies based on scientific evidence, not costs. these meetings are open and transparent to our customers. cost only becomes a factor after this independent committee has identified clinically effective drugs. because optimum rx promotes the
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use of true generics to drive cost lower through competition, about 90% of the prescription claims we administer are for generics. unfortunately, in the case of insulin, there are no generic alternatives. many branded insulin projects are therapeutically equivalent. we negotiate with brand manufacturers to obtain discounts on list prices on behalf of our customers. already, 76% of the people we serve who need insulin pay either nothing at the pharmacy or have a fixed co-pay, most commonly $35. for insulin users on high deductible or coinsurance plans, we have taken action to help them directly benefit from the savings we are negotiating with manufacturers. last year, we dramatically increase the discounts at the
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pharmacy counter for millions of consumers who are now seeing an average savings of $130 per eligible prescription. the savings are even higher on insulin. last month, we announced a decision to expand this point-of-sale discount solution to all new employer-sponsored plans beginning january 2020. nevertheless, the price of insulin remains too high. lack of meaningful competition allows manufacturers to set high list prices and continually increase them which is odd for a drug that is nearly 100 years old and which is seen known significant innovation in decades. these price increases have a real impact on consumers in the form of higher out-of-pocket costs. the most impactful way to reduce and insulin prices is by opening the market to true generics and bio similars.
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this is why we support efforts to reform the patent system in promote true generic competition. for years, insulin manufacturers have used loopholes in the system to stifle competition. one manufacturers has filed 74 patents on one brand to prevent competition. others engage to lower the cost products. congress can increase competition and lower prices by passing the creates act, prohibiting pay for delay deals, accelerating bio similar options in reducing the exclusivity period for drugs. we are committed to doing our part to make insulin more affordable. i would be pleased to answer questions you may have. >> thank you, it is now time for the members to ask questions. the chair recognizes herself for
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five minutes. >> i appreciate all of your testimony. what strikes all of us on this panel, which we have heard from all of the actors in the system, it is how the list price is really high, but then there are workarounds that some people can get to get a lower price of insulin. let me just give you an example. eli lily increase the price of humalog from $35 in 2001 to $275 today. -- and curse the noble log by 350% since 2001. on january 8 of this year, the insulin products will not buy 5%. so, they increase the price of a praetor from $86 in 2092, $270 last year.
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so, since january 1, the three main brands were 4.4 - 5.2% gone up this year. most everybody here knows, my daughter, francesca who is 25 is a type one diabetic. i'm not going to put anybody on the spot, but she is on a newer kind of insulin and she has insurance. she still on my insurance for eight months, who's counting? she renewed her prescription at the beginning of the year and for this insulin it says on the receipt, the retail price, 1739.79. your insurance saves you 1399.79. but the list prices 387 per bottle. now, she didn't pay it because she's on insurance but she still pay quite a bit because i have a
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high deductible. so here's the thing. if everybody is saying the list price is high but there are all these workarounds. but not everybody gets the workarounds. the question is, why is the list price so high. i'm going ask each one of you, have limited time. mr. mason, can you tell me in 30 seconds how does eli lilly justify these huge increases in list prices in the past ten or so years? >> thank you for your question. i hope my daughter is doing well. >> forget about that. >> 75% of our list prices paid for rebates and discounts to secure access of people have affordable access. >> so that's what's making the price go up? >> $210 per vial. >> mr. langa, same question. >> since you heard last week at the ada, there is a perverse
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incentive and misaligned incentives. there is encouragement to keep list prices high. we've been participating because the higher the rebate the higher the list price. >> you think it's because of the rebates? >> there's a significant demand for rebates. >> reporter: i'm sorry, mr. goldman. >> part of how we set list prices we have to look at the dynamics of the supply chain including rebates. we have limited ourselves to list price increases no greater than expenditures. >> mr. marty abbott you have a different perspective. >> rebates or discounts. as we have disclosed, more than 90% of those discounts go back to our client. >> i understand. but why do you think the list prices are so high? >> i can't answer that. that's the manufacturers. >> i concur.
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i have no idea why it list prices are high. it's not a result of rebate. >> dr.? >> we see the list prices rising double digits and nine rebated drugs and generics were monopolies lost or where manufacturers buy up and create monopoly. so, we cannot see a correlation just when rebates raise list prices. >> okay, so of course my time is almost up. i think this is a good example of the problem that the members of congress are dealing with. in trying to figure out how to solve this problem. it seems to me what is happening is that every component of the drug system is contributing to an upward pressure on the list price. i know members are going to have a lot of questions around that. we will do follow-up at the end. i would like to recognize the
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raking member for his input. >> i'm going to use a quick example. just make it simple i been wrestling with this for about a month trying to figure out what's happening. if the chair was making this phone and she's willing to take a hundred dollars for it but she says also it to you for 300 or take a hundred dollars and i say to her i'm willing to pay a hundred but charging me 300 i'll give you 200 back. britney i'm given that to her for $100 because she is the planet saving the money and passing it on to her consumers. were trying to figure out where it's going. and is spending time on it. february 6 the three manufacturers of a few questions. you said that your net price has gone up. what happen if you just said i'm going to make my list price my net price and put it on the
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marketplace? >> first of all, our drop in our list price, for us, there is many people who have access for insulin at affordable costs to their health plans, that is not tied to list price. we don't want to disrupt those by lowering this price. we think the best ways to provide in a short-term is to keep our list price the way it is so we don't disrupt those individuals, we don't harm the access they have. >> but if you're willing to take a think you said whatever than it prices, i know they are different with different plans. but if you're willing to take a net price for your product why would that be something out there for everyone to pay? >> it's more difficult to do that to disrupt that for a product that's on the market place today. people have affordable access. >> but you've had your net price
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according to your testimony go up 207% were your list price drop by 3%. >> i think your similar. i don't want to -- all of you. we see the net price going up. i understand what you're saying but we see the net price rising. maybe there's a market reason and is benefiting consumers. we want to know. >> and the current system today the most important thing is the most number of patients to get our brands at the most affordable prices. in the system today that is the current position, just the three beat pb m's represent over 220 million covered lives. >> that's 80%. for us to lose a position, that would be a dramatic impact to patients in terms of the medicine their own, physicians in terms of their choice. >> you would move your position on the formulary if you lowered your price.
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>> in the current system if we eliminated the rebates, yes. >> he said there were perverse incentives. what are those? >> were spending almost 18 billion a year on rebates and fees. we have people with insurance with diabetes that don't get the benefit. >> what is the perverse incentives for that? >> we believe they should go back to the diabetic patient. >> the issue is not one of negotiation. it is what happens with the result of that negotiation, those rebates are not going through to patients. they're being used for other parts of the system. we don't have visibility for how they get use. they have cost-sharing for the patients covered by those plants. >> would use amyloid to take ask for a product but for me to go on the formulary i know i have to race my my price. >> the rebate is how the system has evolved. they are part of the negotiati
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negotiation. >> i went to long on that. you're ready talk to that. i have other questions i'd rather hear your response to that. >> at smidgen previously, were looking at the clinical attributes of a product. i know you want to get to the economic. this is based on net price. if every one of the manufacturers to the right wanted to reduce their list price there would be no implication to the rebate status the long as the net price remain the same. >> on my example if she's willing to sell 100 and i sell 200 and rebates keep the price down why wouldn't the what would the net price be? there is a price marked through the system that seems to be based on. another higher price that just seems to be caught up in the system.
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what really affects people as we have talked about when they're going to the.of sale, i know you have these plans in place. those are great. we need to figure out the economics behind it. . . . want to submit for the record a peaceful muscle memory. i've done and other hearings about individuals, two mothers that brought brought ashes of front ofldren in cambridge back in november trying to protest these prices. you all have come to know why we hear and you know what the challenges are. i can tell you from seeing her for a couple a self-restraint is to be on the set of dice and watch anyone do this.
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i also, i hope and expect you also understand if that's the result of this hearing that we are not, you're not going to come the status quo will not continue. it can't. we heard testimony from patients that wereat literally rationing, putting their lives on hold for taking serious risk for themselves and the children to get access to medicine that was patented for one dollar. mr. mason, you begin by saying about the 75% of that increase over the course of the past several years increase the list priced goes to pbms. the data ith have indicates over the past since 2002-2013, estimate the average price went from $231, inflation-adjusted, 75% of that is roughly three $75. that means when hundred 27, 50% of the baseline price is not pbms.
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where is the other 50%? what justifies the other increase? >> our net prices have gone since 2019 so, or 2009. we have taken a price increase until 2017. >> have you ever lowereded the price of your formulary? >> we are launching a lower price humalog that 50% off speedy it tookof 15 years and global outcry on this to do it? what factors go into -- have you ever lowered the price? >> we have lowered our net price over the last ten years. >> what factor goes into lowering the price? >> what evaluation? a decade ago we were on formularies, all formularies. now we're on formularies about half the formularies, patients in america have our insulins because we are moving to strictly formalistic we have to provide rebates in order to
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provide to compete so people can use insulin. >> have you ever lowered in this price? >> we have not. >> why not? >> for two reasons. as i said the biggestst vehicle today for the most majority of patients in this country -- s-400li position. that's the best way for us today to reach the most amount of patience and affordable way. anything that risks that something that we have just only consider. every was on the table right now. we want to be part of the solution. people are telling us their rationing the lives of the children. howde does this work? i understand part of this complex and is. i like of oversight to let this happen but from my position at the moment trying to figure out what levers to push and pull, , we're asking what goes into the factors to set that list price? we'll would get an answer to lok price. either he doesn't happen or we don't know. he placeds the blame on the hie of it to go up other pbms and
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pbms are putting back on you. if you're in my position what are we doing to try to make sure patients in this country get access to life-saving medication thatwh was sold to university to ensure every person can get access to it? what do you suggest? >> i suggest we all come together to come up with solutions can get together with congress to make sure that russian ever happens again. as a mentioned in my opening statement, one patient is too many an organization that is been committed to patients with diabetes, it's tragic. >> congressman, no should be rationing insulin. >> but they do every day. >> we need to makeit this patiet more aware of the programs that are available. >> there were people who last you see those programs take weeks toan get into, that is not transparency. they can't wait six weeks to get an insulin shot. >> are copious it's his programs can access in minutes online. so i i did that will plans speey j any patients who don't have access to internet? >> we also have phone numbers --
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>> how long does it take for them to access those programs? what percentage of folks to die? >> for co-pay assistance and -- with literally a matter of moments for the value savings program of access, that we announced today, the expansion -- >> announced today when you are in front of congress? >> a programmer started last year, $99 foru the instant they need and any combination of the pharmacy counter. puk can access it for uninsured patients, those with high deductible health plans they can access co-pay assistance. that's no more than a ten dollars co-pay. >> for the folks on richard painter full list price. >> they now have access as of june, $99 at the pharmacy counter for the insulin they need for a month. >> the chair recognizes the ranking member of the full committee. >> thank you, madam chair for having the student and thanks again for witnesses for being here. in 2018 sanofi launched a follow
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on biologic to eli lilly humalog. according to press articles sanofi launched it at a list price that's about 15% less than the list price for humalog. is that pretty close? >> yes. the lowest list price insulin. >> typically when a generic medicine enters the market we expect the price for the brand to be less. you told us however that it is not on the formulary for any commercial plans. i believe that's great. >> correct, only available through managed medicaid. >> given that it was launched at a list price than humalog, what berries are preventing patients from this alternative, and our species ginny for the access? >> congressman, were unable to secure formulary access through rebating come as exact wisest decisions were made i would have to defer to my colleagues on the other side of the panel.
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>> as sanity faces very spelunking other products? >> yes. sanity has brought a number of products to patients at lower prices including a lower list price of the room toward arthritis medicine and we certainly face challenges. >> given your experience come do you think more follow one eye logic and biosimilars to insulin will help reduce the list price of insulin, or as a biologic market function differently the introduction of the generic of the small molecule drug? >> there's already competition in insulin market as of late one of the colleagues referenced. eli lilly introduced a version several years ago and so there is competition and cds in assessment for to the factor able to leverage greater rebates and negotiate through that. >> i want to switch to mr. mason and thanks for being here. we've heard sometimes a brand of
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biologic manufacture may tell pharmacy benefit managers, pbms and health insurance plans they will no longer provide rebates for the branded product. if the pbm or health insurance plan puts a follow-on biologic or biosimilars on the formulary, has eli lilly told in pbms or health insurance plans that it will no longer provide rebates for humalog if the pbm for health insurance plan puts analog on hisno formulary? >> no, we haven't. >> all right. ms. tregoning, similarly did sanity tell any pbs or health insurance plans that it would stop providing rebates for lantus if the pbm or health insurance plan put basilar under formerly? >> no. >> mr. moriarty, has a a manufacture ever said they would stop providing you rebates for product if you put a competing product on your formulary? >> not that i'm aware of. >> so that's never happened.
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and then for ms. moriarty, whybricker and dr. dutta, isn't it included on your formulary? >> so the challenge that we have specifically is one of net cost. and so to the mechanisms that we use today which are rebates or discounts, it was more expensive than competing products. manufacturers to give higher discounts for exclusive position i think that was your question to my counterpart on the right. >> each of you could answer that. >> yes. to the extent we have recognized one product as exclusive, other manufacturers, that exclusive product will receive less discount if additional products are built in sperber why not include both? >> received less discount anything we do that. >> so what about the others, mr.
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dutta? mr. moriarty? can you speak to this? >> the lowest cost product gets preferential position on her formulary pixel for example, generics which are very low-cost have preferential position. >> okay. >> similar, we tried to lowest available cost, low cost product. example of -- readable to move that the two preferred status and have most if not all patients speedy we keeping the manufacturers should just know the list price and it doesn't assert against a manufacture will have access to patients pr that the facial pay a lower price at the pharmacy counter turkey take the list price of the medicine in consideration when making formula decisions? >> we do not. focus on the lowest available cost lowest net cost. >> the same, yes. both net cost. >> lowest net cost, and for the member can we consider their
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cost by using point-of-sale discounts and, in order to lower the cost out-of-pocket. >> so i just want to follow up on the ranking members questions for mr. moriarty and mr. dutta. why then it you look at generics in the lowest cost, why are not either of your pbms putting united states onn these plans? >> madam chair, we have gone with a file on biologic and research status for the category. >> okay. >> it would cost more to do that. >> why? >> because the list price is not what the payer is paying. they are paying the net price. >> the chair recognizes doctor movies. >> thank you, madam chair. the rising cost of drugs is such
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a big problem that it is reached kitchen table family conversations across america., those families area struggling, worried about having to decide between paying for insulin or paying their bills. it's been a lot of rhetoric today and finger-pointing and the drug pricing debate, and oftentimes the conversation is based on theoretical arguments about what will work for manufacturers or pbms or insurance companies with little regard to what works for patients. as a doctor i put my patients needs above all else and our same andshould do the reduce out-of-pocket costs for patients. in my district according to the health assessment of research for communities .16 survey, one out of four adults diagnosed with diabetes are living below the federal poverty line. over 10% of adults diagnosed with diabetes do not have health insurance that covers some or
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all of the cost of their prescription drugs. this is not just a problem for the uninsured or underinsured either. just this week i heard from tamara smith and david richard, two constituents had to go on a specialized form of insulin that isn't covered by their insurance. that means hundreds of dollars more out-of-pocket every month. so reducing the list prices of drugs or increasing the number generics doesn't solve the problem if these savings are not lowering out-of-pocket cost for people like tamara and david. the ceoor of diabetes patient advocacy coalition drove from this point ind her testimony lt week instating quote, somebody is making a profit and it's not the patient. some mr. mason, from eli lilly, was making a profit from these increases in insulin prices? >> i think first of all we don't want anyone not to be able to afford their insulin. >> who is making a profit with
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increases in insulin prices the patient have to pay for? >> cornet prices are the prices we receive are going down. >> are you excited making a profit?pr are the ceos of your companies making profits? >> our net prices have gone down since 2009. >> somebody is making a profit. somebody getting rich on the backs of our patients. mr. langa, what entity in the supply chain is prioritizing affordability and access of insulin for patients? >> i like to think we are. we participate as many formers as we can pick as an agent that is critical critically most imt with patient assistant programs as well as co-pay assistant programs. >> so is making a profit? >> our nets are going that as well. >> but your overall profit for the company and ceos have been going up, haven't they? >> no. our profit -- >> take-home pay of ceos. >> relatively stable.
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>> so ceo pay hasn't gone up in the past several years? >> his pay has increased, yes. >> so last week the american diabetes association noted that pbms primary customers other health plans and insurers cannot the patient picky>> testified we don't know whether those transactions are benefiting the patient at the point-of-sale. ms. bricker, does express scripts passing the savings on to beneficiaries and how do we know what the difference is if there said that transparency? >> yes, thank you for the question. for over 20 years express scripts have supported point-of-sale rebates. we do have clients and plan sponsors that -- >> how to know what the percentage of the costt savings to patients if we don't have transparency of what the savings are? are they going to your clients, profit, are they going to reducing out-of-pocket costs? how do we know? >> we support transparency for our plan sponsors comes osiris. theyco have the ability to lookt
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all of our rebate negotiated contracts as well as our retail contracts. we believe in transparency for patients -- >> we need to look into what you say and what is being done with implementation and that's what the purpose of this is for. mr. moriarty from cvs health, are these berries to thousand diskettes onto patients at the point-of-sale? if so, what are the? >> with over 10 million flights covered and you heard him a written test on an oral testimony we really advocate for zero co-pay for insulin and other preventive medications. the cost-saving associate with adherence to significant. >> i have 20 seconds. when he asked this question directly. what are each onene of you willg to give up to make sure that every patient and needs insulin will get insulin? mr. mason. >> we are willing to provide solutions and we are providing solutions to close the gap to anyone paying -- >> what are you willing to give up? >> we are willing to give up can we have gave up $108 million
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last year. >> mr. langa, , what are you willing to give up? >> last you invested almost $18 billion in rebates, diskettes of peace and we spent 200 -- >> i get the the price is still going up so the status quo isn't working. ms. tregoning, what you willing to give up? >> we will contribute associates who are not patients access that's why the program have that allows $99 at the pharmacy for the -- >> those solutions are notot working enforcing doubling, tripling costog of insulin and r patients are having to ration and not afford to insulin. >> the time of the gentleman has expired. the chair the chair now recognie gentleman from virginia, mr. griffith. >> thank you, madam chair. ms. tregoning, mr. langa, we've heard their numerous season discount in thehe prescription drug supply chain that are calculated based on insulin prices. according to what i've read you all have fees which are supply chain partners that are based on
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a percentage of the list price of insulin. why are they structured this way? you are a first, mr. mason. let's go. time is running. >> we don't -- the pbms kind of phone the contracts and that's what we have to work under. >> mr. langa? >> it's the current system. >> agreed, current system.e >> have any of your companies try to negotiate flat fees with your supply chain partners? >> yes, we have. >> we have tried a variety of different avenues with contracting. >> but you have not been successful. why? >> know, our efforts were pushed away. >> i think it's because the current system and again it's a demand for rebates today. >> again, this is the way they operate. >> other thann just the system what reasons to the other participants in the supply chain
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provide to justify a fee based on the list price of the medicine rather than a flat fee? >> it's the current system. >> it's the current system, does everybody agree? all that, move on. esther moriarty, in the februart to cvs health, we specific as cvs health to list all the contracts and trends inn existig contracts that are impacted by the list price of a medicine at cvs health did not directly answer whether there were any feeses charged ices that are calculated as a percentage of the list price while redoing the standard contract template, utilize between cvs and health plan client for several lines of business, that the committee received in response to letter we sent to cvs health last august, we saw there was a section and the template on disclosure of manufacturer fees that are disclose that caremark
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part d services they also receive administrative fees from pharmaceutical companies that are based on a percentage of the list price of the medicine. it therefore appears asph though cvs health may use administrative fees that are based on a percentage of the list price of a medicine. this is correct, isn't it? >> congressman, over overnightf all the p fees, rebates that we obtain across our services and 100% and medicare go back to the planof sponsors. >> that's not what your contract says pick your contracts as you walk in charge of 1% fee and, administered a fee based on the price of the medicine. the question that i have is, it doesn't cost your company anymore to process a four dollars drug that does a $40,000 drug, isn't that correct? >> a represent the cost associated with that process.
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>> wouldn't it make more sense from a consumer standpoint that you came out and be more transparent but you came up with a flat fee and worked with these folks over there to come up with a flat fee? i understand partyat on medicare you are just charging 1% across the board according to your information you sent as. you are charging 2% as part of the rebate. you are getting 2% of that and i don't know what you're charging those folks at administrative fee or not, but wouldn't that make more sense to have a flat fee for doing what you are the? >> is a flat fee represents with the current net price, the lower price is an market, yes, we will do that. >> you willing to do that even if the cost your company some profit? >> if it results in lower cost we will implement that. >> because one of bombs>> we had is if you're not in one of the magic companies, you're paying the list price and you're not
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able to afforden paying the high deductible in order to get there because you haven't reached your deductible yet. less people have opted for these plans and so the consumers having to pay that higher list price for not getting all those repeat all the time. as result of that the net price has gone uple substantially and that's where we are hearing from, our constituents have to pay that and seems to me that it ought to be something we all can look at, the whole system needs to be more transparent and you all ought to be paid for processing that prescription, whether it'ss a four dollars drg court $40,000 drug you are to be charged a set standard fee that doesn't have the drug companies come in as a we raising list prices so they can get more. by the way how many billions of dollars or at least hundreds of millions of dollars is represented by that one or 2%? >> we passed back as i said over 98% and we disclose publicly what the retain of her is. the total number across is
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$300 million. >> i yield back. >> hanky. mr. kennedy offered an article for the record, and without objection it shall be entered. the chair now recognizes the chairman of the full committee, mr. pallone for five minutes. >> thank you, madam chair. i missed a lot of the hearing because we had other hearings and we were on the floor today with net neutrality. i just want to say this. all i hear from my constituents, or just totally disgusted. they figure particularly for insulin it's beenn around a long time, you know, they don't even believe in the market-based system in more. frankly, i believe in a market-based competitive system. that's what the country is all about, but what they tell is just set the price. they will literally say to me, you in congress are some government agency should just set the price and that's it. they just don't leaked and the competitive model anymore so you keep saying the system, the system, the system doesn't work.
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i guess part of what i like to know is why this marketplace competitive model doesn't work anymore. what has happened? last week the committee heard from a clinician researcher she said quote, drugmakers take excuses for why prices went up big to say it's a fall the pbms or wholesalers for the high deductible insurance plans, but the bottom line is the drug prices are set by drugmakers. the list price for insulin has gone up dramatically and that's the price many patients pay. that is what needs to come down. it's a simple as that. nd that's the price that many patients pay. that is the price that needs to come down it's as simple as that." now many my contests constituents say that the government needs to set the price, not have the companies set the price. that's not the competitive model, obviously. so let me just dart, mr. mason, he said the list price is not the pbm's or the supply chains. so why are we talking about higher drug prices when it is
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within your power to bring those prices down? why don't you just bring the list price down or do you want us to set it? but the government said it, why not? >> well, we actually buy down everyone in a program down to $95. so we are doing that today. everyone who is on lily insulin at the pharmacy, we buy every prescription down to $95. so we are reducing the list price. but we are paying rebates to get access. >> are you willing to reduce the more? >> right now, no matter how much , they can use multiple vials, multiple pen packs. >> what would be the problem of the governments at the price and just brings it down? >> right now we have competition that's fierce. our net prices are lower today --
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>> so you think competition in the market is working? >> yes. >> i don't hear that from my constituents. it's unconscionable that these drugs are having an increase price, why are they reducing their list price? again my constituents say force them to do it. >> we live in a market-based system and i said if we reduced our list prices it would put all our formularies in jeopardy. this represents 220 covered lives. we don't want to put those lives at risk. >> and let's get rid of the pbm's and we will just, let the governments at the pricing you don't have to worry about the pbm's. >> i agree with you, but nobody thinks it's competitive anymore. >> if you look at our average rebates in 2014 was 40 %. the average rebates just four years later in 2018 with 60 %. that's 40 % increase. we spent up to $18 billion last you in rebates, discounts and
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fees to provide formularies. b all right i see you are just passing it on to the pbm's. same question, people are forced to ration their insulin because they can order. why don't we just set the price ourselves? >> congressman unfortunately under the current system simply lowering list prices might not help patients and actually could cause some patients who are on those formularies where we secured position with rebates to lose access. >> but if we set the price there would be no pbm's anymore. >> congressman believed that the market based system is important for continued innovation. >> you guys have to convince us that it's working. the problem is we always have to end up interfering with the market when it becomes monopolistic, when it's not marking. and my constituents say it's not working. >> congressman,, petition is
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working, the net prices are down, the issue is that the net negotiations are finding their way to patient care. the patients that are exposed to those high list cost the fact that they are having those low list price is and covering to copious assistance, but we don't control out-of-pocket cost. >> adam chair my cost is up but everybody just blames, the pbm's blame the companies and the companies blame the pbm's and mark constituents say they are all no good just get rid of the system. and i'm not willing to do that because i believe in a market- based system. but this is what i hear. >> thank you mr. chairman. the chair now recognizes mrs. brooke's from indiana for five minutes. >> thank you mme. chairwoman. i think everyone's focus and the answers all seem to be focused on the system which i think we all are acknowledging and the system seems to be
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broken. in the february sixth letter that we sent to the manufacturers, we heard is becoming increasingly common for insurers and pbm's to only offer one insulin based on their formularies. and i want to ask them questions about formularies. and, because it sounds like everyone in the finger-pointing is having to do with formularies and so i'm curious, , being involved, we are learning more about the system, why is it that you might have one insulin on a formulary? why wouldn't you want all of the to be on your formularies? and i also have a question, because if you are, saying employees daughter or son and you are used to one insulin, then the company switches their insurance program and they have to go to trial to go to a different insulin, why would we
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not offer as many options as possible? why do we make this change? and then the rebates get in the middle of it and the discounts, can you just help us? the system seems really broken and it sounds like that is part of it. >> so, thank you for the question. the first assessment is purely clinical. it's about whether or not a product is unique or if there are therapeutic alternatives. so when you have a unique product, the price is high, it's put on a formulary, there's no competition. then, as manufacturers produce more products that are therapeutically equivalent, in the case of insulins, rapid acting insulin, long acting insulin's and in the category, then there's to be opportunity when there equivalent to
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negotiate price down off of list price. however, to your specific question, if there is a patient who requires the medication that is not our preferred product, or not formulary, we offer a process for the patient and their doctor to request and provide rationale for their product, and if there is a good reason like an allergy or something like that, then they would be allowed to have that product. >> thank you, ms. bricker, what would happen in the market for you to happen, not you not just the company, but all of the pbm's here. but what would happen if you stopped excluding certain insulin products from the formularies? if you allowed all of them in the different categories of insulin, as i understand it, if you allowed all of them to compete and be on your formularies. >> thank you for the question we don't have one formulary we have many, many, many
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formularies. the formulary that provides the greatest savings for our client actually limits through exclusivity or exclusive placement insulin options. we do that because we are able to procure the deepest discount from the manufacturer once we reward that placement. so they are offering discounts in place for market share and access. but to your point, we have other options and we believe that choice to our plan is critical and they absolutely can't select formularies. >> and what if we remove exclusivity from formularies? >> prices would go up. >> and why do believe prices would go up? why do you think prices would go up if all of the companies were able to be a part of your formularies? mr. moriarty? >> because the drug companies would not offer the discounts that currently exist in the system. >> if we were to remove all exclusivity from x from formularies.
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>> our rebates went up during the. that had dual access to exclusive formularies, that's what those causes prices to go up? >> our rates have been competitive for years. we believe in choice, choice for the physician and choice for the patient. a physician should be able to use their clinical experience to use their medication, not a formulary. >> what if we got rid of discounts and rebates? >> we have a system where you have patient access and affordability if it could be guaranteed we would be happy to move is that system. >> and if you had systems like would you lower your insulin prices that would be offered? >> if we could be insured that patient access and affordability would be maintained we would certainly be willing to lower list prices. >> we support that as long as
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there's access and affordability, we are open to that option. >> thank you, i yield back. >> the chair now recognizes the gentle lady from new hampshire, ms. custer. >> thank you for your presence here today. in new hampshire we have 121,000 , give or take 10 % of our population actually have either type i or type ii diabetes. and these are the people that i have in mind that we have been hearing from. but i want to understand, the frustration that diabetic americans come not just from the dramatic increases in out- of-pocket cost, with the mindnumbing complexities of how the drugs are priced.
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and a belief that manufacturers and pharmacy benefit managers may have lost focus on who they are truly meant to be working for, the patient. so that's really where we are coming from is to try to understand as we unravel this. and you have heard some of the ideas here which i imagine would be a dramatic change in the way you do business, certainly from the conversations that you have with the pbm's that from the manufacturers point of view. i don't think anyone really comes to this with totally clean hands because you are chasing the profits of the quarterly earnings as well as anyone else. and i think part of what is difficult for us to understand is these are medicines that have been around for long, long, long time without a great deal of innovation. without a change in the chemistry and the medication itself. maybe there has been a change, i understand in the delivery
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mechanism, you know maybe there's a medical device change having a longer lasting impact on patients. and certainly for patient convenience and patient health, that's important. but we are trying to get to the bottom of why this has gone up so much. it is one thing for us to consider that in the field of medicine that has it a dramatic new innovations in the r&d costs , but it's all the more complex for us to sort that out. so, i want to get at two areas if i could, just mr. mason, what efforts would you recommend to congress to improve price transparency for patients? you obviously have taken a stand on getting rid of rebates and those types of things. but what is it that should be happening in terms of the patient understanding the pricing? >> we are open for transparency
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to help patients. i think the biggest issue what we are hearing right now, we want the same thing we are not the ending the system we are just explaining the system. we want reform, we want anything that provides better access to patients. the heart of what we are hearing from patients in high deductible plans, about high levels high deductible plans will take the rebates that are given to them and to use those for affordable care for those with chronic diseases. about half of us put that back for the general population. so what we hear and what you are probably hearing is from those individuals who were in those high deductible plans where the employer has decided i'm going to pick the plan design that gives me lower premiums because they are for prioritizing and making that decision. and that leaves individuals with chronicle medications and
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a gap. the most what we are hearing, a stopgap measure to buy all those people down to $95, that's a short-term fix. long-term fit would be to focus on what would be done to high deductible plan so they have affordable coverage from day 1. and that decision is universal. >> so, you would agree that there is discounts for volume purchasing? and are you saying they fall outside, and i can ask ms. bricker to explain, but let me go to you, ms. brooker, how do we get to transparency for the patient? and how do we get all the patient to benefit from a mechanism that it seems to me
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you describing as a volume discount essentially that's with the rebates are. >> a couple of things, if i may. we believe strongly in having real tight benefit checks at the time of prescribing the position has his or her fingertips, what products are covered in the formulary and what it will cost the patient. it's absolutely critical to ensuring there isn't friction at the counter. transparency also to plan sponsors so they understand the value that we have negotiated for them by way of rebates and discounts. so, of course you got to continue to do more. as mentioned previously we announced program for $25 insulin for all of our commercial patients. but clearly, we are still faced with problems in the part d benefit and we are continuing to modernize that benefit so that patients have caps and don't have exposure to high
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list prices, essentially. >> thank you. and gentleman from west virginia is now recognized for five minutes. >> thank you mdm. chairman. i apologize, i have been at two other committee meeting so i've missed some of your, but i have heard enough of it. so mr. langer, i probably want to focus most of my remarks to you. i will just begin for my records, we have some information in a vial of insulin in 1967, it went up $17, but yet your novolog is now a list price of $217. so many times when we have our meetings back in the district in the roundtable discussions, they talk about how people in west virginia are no different from around the country having three and four dollar, i talked to one gentleman who said he just wrote a check for thousand dollars for his insulin. it was in excess of his
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insurance. what i was hearing, only similar dollar increases like this. but i was hearing all of you say it was caused by innovation and in part by innovation. so i'm curious, what kind of innovation have we implemented over the last few years that would cause such a drastic increase in the price of insulin? the innovation part of it, because i am a strong, strong supporter of innovation. so help me out a little bit why is innovation causing the increase in price? >> innovation is important and what's most important i think what was mentioned earlier is we have the patient in mind. is incremental, it's not incremental to the patient, so when you talk about going from 4-6 injections per day to 1. you think about basal insulin,
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the best way to describe it is to describe patients is because of the mission that we are on, we sometimes, >> i don't need someone to filibuster on me here. >> i have a patient that is living with night terror, and that's low hypoglycemic issues and that causes them to do things out of character. and because he got on a drug he has not had a night trimmer since. >> work prior to having the innovation, the prices were lower, now they are skyrocketing up to 237, can we just stop the innovation? if it worked before, why in the
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last five years through innovation we've gone for 17-$20 , i don't want to go there because as an engineer i believe very much in research and to do that. but if we are driving the price up, innovation is supposed to drive the price down, not up. so i'm really troubled with it. >> innovation today and tomorrow is important because we are working for the future of people living with diabetes. >> i'm going back to why until the last years i'm sure you're innovating back in the sixties and seventies, but it wasn't skyrocketing like it is now. so it's just counterintuitive that white innovation is driving the price for the last few years. let me go back to the list prices, because we are going to run out of time. but i understand, i come from the construction industry. but also, in life, i need to
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see some examples of why we have these list prices set up for discounts, i've heard you talk about, if we don't have rising list prices for cars and appliances, and construction material, why is it the pharmaceuticals are jazzing up the list prices so they can offer discounts? why is that unique to pharmaceutical fields? ? you heard a lot about this but it's about these misaligned incentives in the system. the higher the rebate, excuse me the higher the list price the higher the list rebate. and that is, and those rebates don't get passed through to the people living with diabetes. and there in lies the challenge. >> should we eliminate or discourage the rebates? >> certainly, we are supportive of the rebate role and we are
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supportive of the pastor of those rebates to benefit the patients and we think that would be something that would be healthy for patients. >> okay i've run out of time, i am sorry, i yield >> thank you, chairman for holding this hearing to tackle the skyrocketing insulin price. i recently met with a family from back home in tampa and nine-year-old broke and her father todd explained to me how she was diagnosed when she was three days old and hospital and how they have struggled with her diabetes since then but it's not just the big struggle has only been on the health side. it's been with affording insulin and drugs. they had to change their lifestyle a a little bit. todd told the 1. they had run out of insulin two weeks before the end of the month and had to borrow a bio from an adult friend of ours who was using it and had numerous files stockpiled. that's how we do it now. we tell our endocrinologist we
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use more insulin we need in a month so she writes prescriptions for slightly more than we use. since the files are good for two years with extrawe in case anything happens. at the end of the day we count ourselves blessed both public and i work and are injured sufficiently helps pay for all of brooks type i diabetes supplies but the beginning of the year is still very difficult intent with our deductibles and we choose to pay more for our insurance for out-of-pocket to make this deductibles but he says i cannot fathom how a a family can choose to limit or ration insulin to their children. the system needs to be fixed. i asked brooke, as the nine-year-old having to deal with this what would you want me to ask? she said why do with laws that protect kids safety, like by come, seatbelts and indoor smoking bans, but not laws that would allow them to get the medicines they need to stay alive?
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so things have got to change. let's start with manufacturers list prices and have get them under control. seems to be just but a good and supply chain except the patient is benefiting from increasing list prices. mr. mason, if rebates and fees tied to list price were to be restricted or eliminated do have any guarantee from eli lilly the prices would go down in patients with a list? >> we would definitely considerate. >> mr. langa? >> we would consider that come yes. >> is there a guarantee? >> what's important to us again the majority of patients cannot access that a i formal pricing d as long as there's that in place and yes, we would consider it. >> ms. tregoning? >> as long as we can ensure patient access and affordability and formulas then we would lower list price with elimination of rebate. >> there's another hitch in the system here and that's the gaming of charitable contributions. it's been reported somete manufacturers use the patient assistance programs to reduce
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their own tax burden, that by donating drugs to the patient assistance programs the company is able to deduct the value of donated drugs from its taxes. in 2015 understand eli lilly donate 408 million worth of drugs to the care foundation. mr. mason come should manufacture be able to benefitit financially from the patient assistance programs? >> we do it until patient there will want anyone not to -- >> that's a big, 408 million, then i would think we would seek some commensurate reduction of the list price that would be tied to that. >> are net prices are goingng down. what you are not seeing is we spent $108 million last year on, that help offers 525,000 people. those are not tax write-offs. >> there's an issue here with these kind ofpe charitable contributions.
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using the babysitting on both sides and patients arek not. turning to the pbms, ms. bricker, if he's paid to wholesalers are standardized and entirely delinked from list price, what impact wouldg have what the patient ultimately pays? >> over 50% of our clients receive all fees that are collected from manufacturers here at 95% of all fees and discounts rebates are passed on to our plan sponsors and so ultimately when you the link that the from the list price there really is nothing that prevents thedi manufacture continue to increase the price. >> so the mission of pbms is to get the lowest price possible for drugs for their clients but that clearly isn't happening. how can we change the system to better align out-of-pocket patient cost to negotiate a net cost instead of the list prices? >> 76% 76% of never scrape the y
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zero dollars co-pay or most commonly a flat co-pay of $35. for the other percentage that you're asking about that on our coinsurance or high deductible plan, we advocate for point-of-sale rebates as well as preventative drug lists so insulin would not apply to the deductible. >> i yield back my time. thank you. >> thank you. that you are now recognizes mr. mullins for fivemy minutes. >> thank you, madam chair, and thanks for holding this meeting. it's not often we get together and actually agree on issues, but we are all part about the same thing and we're all scratch your head trying to figure out how we got to this point. real quick, to go back to what was just asked about your tax advantage for taking the rebates. rebates. is there a taxt advantage for your companies for those rebates? yes or no? >> no. >> no.
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>> no. >> what about the charitable contributions? is that not a tax advantage? >> we only get insulin -- >> if it's at $300, using generic numbers, if the list pricee is 300 come you put your rebates and, you get all the way down to 100, who absorbs those rebates? us that whys, we're doing it. >> who absorbs those rebates? you guys absorbsbs those rebate? if you are given a rebate and the list as a $300, you get you get to 100, who absorbs those rebates? >> the rebates coded pbms -- >> and doesn't go to the patient though, right? >> based on -- that's the concern we have. >> do you write that off as a general contribution? >> that's different unachievable contribution. the free drug program which are run through patient assistance programs is different, that's providing free trucks toio patit below a certain threshold. that seven from rebate.
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>> going on what mr. griffith asked here in the back, the innovation -- sorry, but cleanly, asked about the innovation. when you're talking about the innovation side of things, are you using insulin today to help pay for future drugs? is that innovation that you guys are using for research? does the price of insulin help offset the cost of research for future drugs? >> revenues from all of our business and part the back to fund research and development across all areas. for diabetes and the united states i would point out -- >> i can understand -- a lot of you guys talk to me in my office turkey say the price of the drugs we can recoup our cost. to develop it. that was the caustic that's why it iss set what is because were trying to recoup the cost of it. i totally get that. you have to recoup the cost especially when you start having
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done so run a need to recoup cost and time. but the cost is recouped in this. so you arere using insulin today to pay for future drugs are outside of insulin, is that correct? >> we continue to invest in speed is that's why you seeing it go up so much. >> no, because our revenue some deputies are going to the net prices are going down. >> budget a heavy cost associated with it because it's already developed come already paid >> the revenue in u.s. has gone down by half last four years. net prices have gone down -- needhave quick questions i to getet to the if the patient qualifies for your programs, how much does it cost come how much does insulin cost at that point? >> patients assistance is free. >> for co-pay assistance to pay no more than ten dollars. if they qualify for the charitable, then it is free drug. >> okay. >> it is free.
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>> ms. bricker, with the express scripts come you guys came up with no more than $25 charge to customers. you just roll it up recently, right? how long did it take you to develop that? >> we've been working on it for a few months. >> as the companies on the agree tove they participate with you? >> yes, they have. >> it took you two months to come up with that. how are you able to offer that? >> in collaboration with the manufacturers as well as in collaboration with plan sponsor sponsors. >> when a patient qualifies for your programs, how long do they typically stay on those patient assistance programs? >> it varies really by patient and programs so they had renewal times but it could be one year, three years. >> do you know what the average patient states are broken?
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>> i really don't know what that is. >> our separate foundation doesn't so we don't have that data. >> okay. i yield back. thank you so much for your time. >> thank you. the chair now recognizes the gentleman from new york. >> thank you, madam chairwoman. like to begin by asking about a number of simple yes or no questions are during a hearing last week patient advocate gail testified against her doctors orders she had rationed and diluted afo bottle of insulin because she couldn't afford to pay the $346.99 it cost her per month.h. are you awarelu of stories like yoursbe looks we will start with you, mr. mason go cross with yes or no. >> yes. >> yes, we are. >> yes. >> yes. >> yes. >> have any of you personally ever had to ration a pile of insulin? >> i have not. >> i have not personally. >> no, i have not. >> i have not. >> i have not. >> no, and no which it.
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>> i hear stories of my constituents frequently about afforduggle to life-saving medications, including having to make tough choices about putting food on the table or simply line by medication. have any of you have personally had to choose a tween feeding a or buying a life-sustaining medication? >> no american should. >> no, i have not. >> no, i have not and i agree no one should. >> i have not and no one should. >> i have not and no one should. >> and a broader sense, have any of you ever struggle to afford the medication that was recommended to you by your doctor? >> i have not. >> there once was a time when one of my children had to be on a growth hormonene product and e were not able to get reimbursement because the type who would be several thousand dollars and would be a challenge for us so yes, there was a time
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in my life. >> thank you. >> i am fortunate not to face the situation. >> i have not. >> i have not personally i guess my family members have struggled. >> no, i've not. >> i thank you for your candidate i want to be clear that i'm not asking these questions as a gotcha moment but as reminder that we need to approach this issue with empathy and compassion. we never know what the person next to us might be going through. these stories we've all heard and assuring today are from real people, modern medicines like insulinn saved lives but when te dangle this life-sustaining medications medications just out of reach on thoseda who need th, we are engaging in a most cruel of torture. according to testimony last week, one in four individual reported using less insulin than prescribed over the past year, specifically because of cost. let's put ourselves in their shoes for the day. we can get bogged down in washington with the blame game and talk about esoteric issues
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like rebates and list prices and patient assistance programs, but the reality is that when i go this weekend back to my hometown the amsterdam new york there will be people in my community that are in the hospital putting their lives at risk because they're so desperate for this medication that they are priced out of themhe that they delibere let the blood sugar crash just so they can get free samples of insulin on their way out of the door. regardless of where you in the blame, the system as it exists now is horrendously broken and the companies represented at the witness table are benefiting while patients across the country are losing. that is unacceptable and we need answers. last week in testimony before the committee we heard from the endocrine society that in 2017 expenditures for insulin in the united states reached some $15 billion. they also told us that three of the top ten medication costs were for ali type of insulin. where is all this money going? let's start with you, mr. mason.
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>> our net prices are going down. while we hear so much of why people can afford to insulin today, it's as individuals and have high deductible plans that have high a out-of-pocket costs because rebates are being used to buydown premium. >> do those net prices need to go down further? >> net prices are going down. >> do they need to go down further? >> our net prices are going down. the price that put payers play to get insulin is going down but those costs are not being used to help people who have diabetes. those rebates were used in order to tie down premiums for the general population leaving those with chronic medications like
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insulin exposed with the deductible. that's what were hearing. that's the.that we need to focus on solutions. that is the gap in the current system. the current system is not working, we agree 100%. that is the heart of the issue. >> my time is up. but again, crisis that we need to resolve as soon as possible, quickly. thank you. i yield back. >> the chair recognizes the lady from new york for five minutes. >> thank you very much area and i think our ranking members, this is a very important hearing today. i wanted to ask a couple of questions. we've heard some examples of the dramatic rise of insulin prices this afternoon. i am still not clear on the flowchart. , it's, we have heard a whole lot of different things about
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pricing, list pricing, and that night pricing is going down, is that what you're saying? okay. now, is that subject to at and flow? in other words if your same prices going down as we sit here, is there a.where that price gets settled at a lower price? or is there a possibility that it rises again? is it like oil? >> no, it is not like oil. this has been pretty flat over the last ten years. i think we've had the data as part of our written testimony. >> how was it than that if they are going down over the past ten years that it still is an affordable? that's the flowchart i'm talking about. first of all, despite for some strange reason. i guess the change in the system for the modernization of the system that included this rate
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shenanigans. that's what it is at the end of the day. if you have a 100-year-old product that increased in value because all of these other dynamics got involved, is the same product. so, can you give me a sense of what happens when you produce this product? what the cost is and then how it gets to the.where the average american can afford who needs it can't afford to access it? that is the crux of this for the listening public. we have talked about a lot of terms of art here. but americans need to know how you got to where you are. given what we know. can you explain or is there anyone on the panel who can
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explain in laypersons terms? >> congresswoman, the insulins of today are very different than the insolence of the past. i think that is important to keep in mind. the insulins today. >> we understand that. in terms of the list versus net prices, the net prices have been going down steadily. we talked about our insolence thins the price has gone down 25% since 2012 and that is expected to continue. the issue is the savings. >> what precipitated that? >> additional competition in rebate. >> are you sure it wasn't the outcry of the public that could never afford it watering down there insulin? >> on virtually the lower net prices are not finding their way to patients to your. the rebates that exist in the system, the gap is being used to
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subsidize other parts of the system. >> so the system became far more complex over time. is that? this system became complex and rebates generated through negotiations with pdm serbian used to finance other parts of the healthcare system. >> did we extract rebates from the system, what happens? >> if we move to a system we support the rebate rule. then we would be able to lower our list prices, but we need to ensure. >> no. i just want to know if we remove the rebate, i think you had. >> if you remove the rebates, their discounts, there is no one advocating for the patient and the plan sponsor to drive discounts and affordable. the rebates are discounts. it's a volume discount.
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so, pbmc server critical function and serving affordability. other people who slip through the cracks? absolutely. were committed to serve each and every patient. doing array with the rebates will only increase costs. >> we support having rebates passed through to the patient to use the drugs upon which the rebates have been negotiated. >> this is a circular issue. because you want that passed on to the patient so you can continue to push up the price. >> we don't receive list price. we received the net price. >> you don't receive the list price. >> no. the price paid to manufacturers is ultimately the net price. >> so. >> is being used to offset other costs of the system what we would advocate for his insuring the rebates are provided to patients who are using the drugs upon which the rebates are
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negotiated to lower their out-of-pocket costs. >> are you saying that the pbmc demand for increased rebates is the reason you are forced to keep raising your list price? >> it is one component. we have limited our list price increases but one component of that decision-making is the deny mix of the supply chain. >> what are the other components? that includes the need to continue to invest in r&d in the competitive environment. >> i yield back. i think it is more p&g. i yield back. >> i recognize a jonah from maryland for five minutes. >> thank you. the rebate, is the rebate system transparent right now? would you say? >> the rebate system is 100% transparent to the plan sponsors and customers that we service people that hire us, employers
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of america, the government, health plans, what need we negotiate for them is transparent to them. >> so we can track the list price and we can see the rebate and then we can see the net price and then we can see the savings that you pass along to the consumer, that's all completely transparent to the public questioning. >> is not transparent to the public unless they are our patient. but. >> should it be? should it be trade secret? is not the problem proprietary. >> the reason i'm able to get the discounts and came from the manufacture. >> it's a secret. >> because it's a secret. >> what about if we made it completely transparent. who would be for that? >> we would support transparency along the entire chain.
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that's the important thing if we have transparency along from the list price all the way through to patients. >> to all support that? >> absolutely not. >> you can't, because then it will end up hurting the consumer. >> will hurt the consumer to have transparency. >> will hurt the consumer because -- >> i don't buy it. i think the system has been built that allows for gaming to go on and you've all got your talking points, you have said that you want to guarantee patient access and affordability, at least ten times. which is great. but, there is a collaboration going on here. i know there is this going on but the system is working for both of you at the expense of the patient.
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now, i reserve most of my frustration for the moment in this setting for the pbmc. because i think the lack of transparency is allowing for a lot of manipulation. i think the rebate system is totally screwed up that without transparency, there is opportunity for a lot of hocus-pocus to go on. with the rebate. because the list price ends up being unreal in certain ways except to the extent that it leaves certain patients holding the bag then, the rebate is negotiated but we don't know exactly what happens when the rebate is exchanged in terms of
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who ultimately benefits from it. and, i think we need more transparency. i do not buy the argument that the patient is going to be worse off, the consumer is going to be worse off if we have absolute transparency. i think just to get the lobbyist in the room to shudder a little bit, i think the pbmc should be utilities. or converted to nonprofits. or something. i know when we started out i understand what the mission was originally. of the pbmc. it's a complicated industry, you need an intermediate area to assemble the information on both sides to weigh in, to assemble
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the bargaining position so that you can get the best pricing in the early days, that was a good argument. but, now, things have gotten out of control. you are too big and the lack of transparency allows you to manipulate the system at the expense of the patient. so, i don't buy the argument that the patient and consumer is going to get hurt if we have absolute transparency. if we can get in for a for-profit entity like the pbm, we had a look at other ways of doing it including have the government get into the space in came pete and providing that function. with that, you'll back my time. >> the chair recognize the gentle lady from illinois. for five minutes. >> thank you manager for holding this hearing. i don't know if i have any questions at all. but i want to tell you something, and the 2018 election, the number one concern of americans, the high cost of
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prescription drugs. we have the names of people who have died because they cannot get their insulin. a young man who was trying to control it himself after going off his parents policy. dead. we know that a huge number of people are not taking the insulin that they need because they cannot afford it. so, they get sick, they get sicker, and maybe they died because of it. i don't know how you people sleep at night. the tween 1996 and now, when you have eli lilly from $21 a bottle to 275. you heard mr. mckinley, who went through all of that, interesting, by the way so for
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eli lilly, it is now 275. for -- it is $270. fern orders is to $80. curiously close in price. and way too high. i want to tell you something, that will not stand in this congress. i heard ms. brooks say the system is broken. i think on both sides of the aisle there is a commitment. we have evinced heard the president of the united states talk about price gouging. yes, we need transparency. i have a strong transparency bill that is going to hold you guys accountable. and make you notify how you justify raising those prices. you talked about another,
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mr. langa, you talked about another drug that you are developing and that somehow that's an excuse because it helps diabetics and that's the research and development that you do. you're in trouble. the lobbyists out here, maybe that's you, they need to understand that this is a commitment on the part of the congress to get drug prices, particularly lifesaving, life necessities to get those prices under control. if you think you can just out talk us without any transparency, without any accountability, i just want you to know, your days are numbered. you know when mr. azor became
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the secretary of health and human services, i wanted to remind him that he came from eli lilly at the very time those drug insulin prices went through the roof. and, we are seeing that on drugs that have been like yours on the market for decades. if you want to try and explain, i totally agree, isn't that a good three that now people may be able to take one vial and not have to shoot up all the time because in the delivery system. but, we have no clue if that means you can raise those prices 1000%. and you think you can get away with that secrecy, or just blaming the pb mediums. i'm not holding them on accountable. we need to do that, but don't excuse yourselves from this and
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don't tell us about the wonderful charity prices that you give and then you do get tax breaks on assuming, contradict me if i am wrong. when you give charity care to people. i believe that is a tax-deductible kind of item for you. i'm not hearing anybody contradict that. i resent that very much. because then everybody else is still paying those very high prices. so, just know something is going to happen here if you don't decide in your own interest to lower those prices so people don't have to die. i yield back. >> the gentleman from california, mr. peterson is recognized for five minutes. >> i've heard a lot of discussion. it's been very -- for me.
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actually, i don't want to blame you for a system that we have set up here that encourages this bizarre incentive. the fact is, it's a system that incentivizes people to charge higher list prices so they can get give rebates to give them access to customers. i'm a believer in markets, someone called this a free market. it's really not. i don't think we should suggest that this is the type of competition that will take per care of our problems. what we have here is what economists call a market failure at best. that's when it's appropriate for government to take action in a capitalist system. i think most people agree with that. i think that's what were going to see. we are going to have to take out the incentive to charge higher prices so that you can get the customers had no knows what the real prices are.
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it is impossible for us to understand. we have access to this information. this is an opaque system. you're going to have to change that. i appreciate the input, i don't ever suggest that companies are not going to make money when they are allowed to do it. i just think this is a perverse system that has to be changed so that if we want competition we get real competition. but the system of rebates is really encouraging and anticompetitive behavior. also i know that i'll just express a concern this is in the courts, but now we have companies owning pbm some plans without any insurance of the relationship between the sister companies, the pbm in the plan. again, there's a real risk of anticompetitive behavior. i think you've comment on the
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best job you can answering the questions. it is a system that no one should have to apologize for but it's a system we need to change in congress. i think that is what you will see going forward. i yield back. >> the gentleman yields back. we now have several members who are not on the subcommittee but who have been gracious enough to be here for most of the hearing. i appreciate their attendance and their input. so i like to first recognize congressman -- for five minutes. >> thank you miniature woman. i was a physician before icing congress of these issues are extremely important to me. for me, it's all about people and taking care of people and making sure, especially when it's a life-sustaining drug. i appreciate your input. it is a system that needs change. we did a hearing last congress, we had eight stakeholders in the entire supply chain. we have pretty much got this the
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whole time. i get that, i'm not blaming anybody. i just think we have developed a system over time that is going to need change. i have a question for both pbm sand the companies. doctor , i understand that representatives from your company testified in front of the senate finance committee yesterday. i understand your ask questions about contracting -- and relationships grid i would like to follow up on the can you talk about, it has your company ever proposed in contract or demanded that manufacturers give advance notice of list price decrease. i remind you we are home under oath here. we have access to information potentially that could counteract a question or answer
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that is not accurate. >> yes. >> and manufactures pay a higher fee, rebate if list prices do not increase above a certain percentage in the contract year? for example if they don't increase their list price above a certain person that they may have to pay a higher fear rebate for that drug. >> i'm not aware of that. >> and manufactures pay certain rebate amounts even if they decrease their list price? if you have a list price and the company says were going to go down to hear in the rebate was based on the higher list price, does that amount stay the same question right. >> i'm not aware that. >> the same question, you have contractual otherwise demanded manufacturers give advance notice of list price decrease question were. >> know. and the manufactures pay higher fee of list prices do not increase above a certain percentage of that contract year? >> no. >> and manufactures pay a certain rebate even if they decrease their list. >> no. >> we hear that they do.
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>> same thing. do you have contractual relationships that otherwise demands manufacturers give advance notice of decrease in the list question were. >> no. >> the manufactures pay higher fee if these prices do not increase? no. >> and manufactures pay certain rebate amount even if they decrease list? >> no. >> we are all about net price. >> i'm going to focus on the 340b program. i've been an advocate for reforming that program. information that notice provided indicate many insulin products are at penny pricing and the 340b program. information they provided the committee show that for one product at penny prices the number of packages provided to entities increased from just over 270,000 packages in 2014 to over -- packages in 2018.
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more than 172% increase in the number of packages supplied to 340b entities. many insulin products saw increases in the number of packages sold the program during this period. can you explain the impact this program has had an orders pricing in the private commercial markets? >> we have over 18000 facilities at this., it is a penny pricing, is literally 99.9%. packaging is i believe as you reference it. it has been going up. the question is, the influence on the commercial market. >> because of the penny prices and the volume has gone up dramatically has that had an effect on the overall pricing structure and the rest of the marketplace? >> the challenge has been the 340b entities and who actually gives the designation and not. that is been more of the challenge.
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>> mr. mason? >> same thing. 340b has dramatically expanded as we know. >> obviously it does take away our net sales. if those are legitimately helping individuals that need that help, we are finding that a product is going. >> quickly, amount of time. >> i think the issue is heavily discounted products that go into the 340b system. those heavily discounted prices making their way to patients? >> with your indulgence, in a 340b program i believe based on this subcommittee that was released last congress we need to seriously look at and reform the 340b program so that it continues to exist for the hospitals and patients that need it. but add a degree of transparency because it is spiraling. thank you.
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i yield back. >> thank you. we now recognize the very patient woman from california for five minutes. >> thank you very much. i'm sitting here and i've been hearing this back-and-forth for the last couple of hours. the way i think i would summarize this is, it sounds like we are playing a middleman, it just sounds like were playing a middleman for prescription drugs to be on a preferred list. thus not just to put all the blame here, but then these list prices have been skyrocketing when we ask about pricing we hear back from the drug companies we hear, the net price is actually declining. the last time i checked i think willie was doing pretty good. wouldn't you say so mr. mason? why don't you tell me what the revenue was for this coming year what is lily's revenue this coming year? >> $21 billion.
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>> $25.3 billion for the coming year. your ceo in 2014 was making 14.5 million and a pay package. that was in 2014. the new ceo in 2018 is making $17.2 million in a pay package. you guys are doing okay. i would think so. the american people see that and say, why can't we just get pricing for insulin, a life-saving drug that we need. not that we want, but that we need need. and they say congress has to do something. when you hear what is happening today, that is exactly what is going to have to happen. i don't see anything happening here. i represent a congressional district that is a majority minority. people of color are disproportionately impacted by diabetes. latinos, african-americans, i represented district that has very low income working-class families were struggling. my reports is over 80000 on his
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shirt. a lot of people who probably cannot afford to pay for their insulin. do you all recognize that your pricing policy and your system is causing people to die every day? do you all recognize that? mr. mason, do you recognize that? let me just go down the list, yes or no do you recognize this? >> we don't want anyone not to be able to afford their insulin. >> i understand that. you recognize this pricing system and model is causing people to die? >> we need to do something about it collectively. >> that's es. >> we recognize the model is certainly a challenge, yes. >> and you are playing a role in that model. let's not mix any words here. these companies in the pbmc are playing a role in this model. that is why we are having this hearing. to get to the bottom of it.
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>> yes, we recognize that is happening and that is why we put into place the programs to address the inadequacies of the current system so that it doesn't happen very so people are not forced into rationing their insulin. we don't want to see that. >> there is no question there is a portion of the population for this need to be impacted very directly. >> absolutely their patients falling through the cracks. we exist only to make medication more affordable. >> i'm not going to get you to to tell me that you are part read the reality is what we heard, that is what is happening here. i wish that you would all come together and collaborate. a moment ago i believe you said that the way you are able to get the 25-dollar plan and the deal that you are able to get for the insulin in the new program you just rolled out as you collaborated. you work together. so, if you could do it there, how come you can to it for
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others? and so, this is where congress has to step in and do something. it's because of profits, it's because of greed, the american people are tired. and when people die, when people die and that is what is happening, make no mistake about it. we hear about it, the country hears about it and it is outrageous. it is completely outrageous. no know. . . do you support medicare being able to negotiate prices? >> prices are getting better.
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>> yes or no? >> i think it's needed. i think everything we considered -- i think we consider a fair amount -- free market right now is working because we have some of the heaviest discount. >> is not working, people are dying. >> very effective negotiators, the question is what we do? >> you have an answer on whether or not you support it? >> do not negotiate. >> do not. >> we do not -- >> yes, -- >> we do not. >> i understand why that might be the case. that's unfortunate but my time is up. >> thank you. >> directing mr. --
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>> thank you for allowing me to participate. full disclosure, on the only pharmacist serving in congress, i practice pharmacy, independent pharmacy for over 30 years. i remember and fyi, i started when i was ten, i remember when they evolved. i remember when it was nothing more than a processor. also we did was process claims. i remember what was incorrect from drug companies and not going for anyone, just getting a shipment every week, delivery every week from any other nicompany. any of the numbers that we ordered from. my colleague mentioned earlier about patients having to make
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choices between eating and paying for medication. i've seen it firsthand. i have witnessed it firsthand. you said you were a pharmacist, i don't know what your experience, your younger than me but at the same time, i tell you i have seen it. i have seen patients at the counter having to make a decision between buying medicine and groceries. i've seen mothers in tears because they couldn't afford their medications. i've witnessed it firsthand. that's why i am so passionate about that. i wanted to start with you, during a briefing with committee staff, i don't know if it was you or a member of your representative of your company, they started in increase more rapidly around the same time there was more consolidation throughout the pricing supply chain. there has been increasing demands on that. has consolidation impactedg. th? >> i think as i mentioned, represent almost 220 million. >> that's probably the
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representative between 70 to 80% of all. >> correct. >> would you agree with that? i believe you responded topo a letter and said the same thing. >> okay, i'd like to argue, cbs is a drugstore right? and its owned by cbs the same company. we have the insurance company, and the drug story, all the same. i believe expects representing the pbm. you are also, you just out cigna. you also haveng your own order forms, correct? and same thing with you, the pbm
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united healthcare insurance company, you also have your own mail order pharmacy correct? >> united healthcare sister companies, yes. >> you do have mail also? >> optimum rx. >> okay. nevertheless, when you say during the hearings your returning money, can you say if it's insurance company? >> it is the employer's. >> are you sending the money back to the insurance company? >> more than just health plans, yes. >> you're sending it back to insurance company? >> we send it back toch the. >> you send it back to thee insurance? to send it back? >> in the event that the have
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the insurance company, yes. >> right. same thing with you? >> in the event that the sponsor this. >> then think the same thing, not managing money, back to another company that you own. >> we have many health clients. >> i understand but it could be possible if you're sending it back to the same company. this is what we are talking about, that's something that we need to be aware of. let me tell you, before i relinquish my time, i want to congratulate all of you because you've done something here today that we've been trying to doti n congress for ever since four years and three months i've beeo here, that is create by partisanship. what you witnessed here today is bipartisanship. this is going to end. i have witnessed it and i have seen what you have done. i see what you're trying to do now. let me tell you, with the cms is
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proposing in a way of doing away with it and discounts at the sale, that will happen. we will make sure it happens. that will bring more transparency to the system and we will not stop there. >> thank you. i was just saying, i never thought i would see this, he was channeling him. [laughter] congratulations. i nowu want to recognized you r closing questions. >> when the chair and i were discussing having a hearing, we saw it was a problem. i know it's different than 100 years ago but we had a lady before, a doctor and physician from yale that said the same incident from 90s than it is today. it's moved forward and we want to to look at the entire system, one drug that affects all.
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diabetes affects almost every family. you can see what's going on and extract late it, just to talked about trump think this is important experience. drug pricing is important. everybody is uniting everyonepe i'm going to be quick. i will ask the question because that's not what i'm recognized work but so from yesterday father talking about his daughter, not having any symptoms from sickle-cell, hepatitis see, medical devices, you can do artificial pancreas so innovation and market-based system is absolutely important. what we are trying to get out with this is that hopefully our frustration is that we see
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pharmaceutical companies say that prices going down. we see the list price going up and we friends down the road that are in the situation, they see, the situations he just described. they have to play the list pri price, when they saw, cash flow to those businesses. what we are trying to figure out is if the price is that price, why isn't that -- if the idea is we are going to get the lowest price for our insurance companies, why is her $135 that cost 135 rathere than seven something three or 400 and getting three or 400 back talk about where the money is going. this is an informative, one question, what you put on the formula? is it better for high risk price for the lower net or is it
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better for the insurance company, but not as good for a lower net price, lower list price, lower for the consumer. hopefully the beginning of the series of hearings, we do appreciate your willing to come here. trying to inform us, we do have to make some you could get into harassment and shortest. that's not where -- that's not . at i want to go. we want people to have a fair price they can pay if they can't been have this, it's life-saving. >> i think -- i do want to think the witnesses. i know people asked hard questions. it was important for us to get everybody in here. i think we can all agree that it's system. people didn't anticipate but
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here's the thing, the people who are suffering the patients. the case of insulin, the people were suffering are people who need insulin every second of every minute of every day. or they will die. that's the issue we have here. i now, having done this investigation last year, with my colleague from new york, tom green and snow doing this investigation, i think i have a pretty good grip. i think the members of this committee are getting a better grip of what's going on. what's going on is a system has grown up in this country where we are continually -- it's a smoke in the system where we are continually increasing the list price of insulin in order to try to do negotiations but somehow it the price of insulin down.
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let's look at the reality of the situation. the members of this panel kept saying over and over, that prices of insulin had gone down. one person even said that nobody pays list price, they'll pay that price. but that's not exactly true. i just want to give you the example of this, it's one of those incidents that's not 100 years old but it's over 20 years old. in 2001, it cost $35. today, no change, it's not the other, it's another drug that's given to type two diabetics. so it's still the same formula. it's $275 today for a bottle of the same insulin that i bought
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for her when she was six years old. the generic one that has come up, it's good news, it's only $137 a bottle. it's still way beyond where it was in 2001. now it has a new generic alternative, i just sat here and looked at it, it might not cost as much as the other but it cost over $200 a bottle. let's not kid ourselves that the generic equivalent of this is really any cheaper for that young woman in my district who doesn't have insurance who's desperately trying to find two bottles of insulin every month. that's $400 for her even if she bought that. when you say nobody is paying
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list price, there are people paying list price. the people paint list price are the people who have highd deductible plans, who have to pay for the list price when they go in toar the pharmacy in their deductible. the people who are in the whole of medicare, and the people who are uninsured and i know all of the, everybody here, ppm and pharmaceutical companies all have the efforts to give cheaper insulin to people like this. going to tell you, the lady i talked to in denver, she didn't know how to get that incident, she had no idea how to get it. our witnesses last week said many people in that situation don't. it's not a solution to the problem, it's just a temporary band-aid. it's one we have to stop with the whole sale innovation. let me say finally this.
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it's not like the pharmaceutical companies or anybody else in the system is doing this for public interest reasons. pharmaceutical companies had $323 billion in profits last year. the p be as had $23 billion in profits last year. everybody is making a profit. the people who are really suffering here are the people who either have to pay list price or even after their deductible have to pay an unacceptable price. nobody here in this room once that. what we're going to do, you're going to get together in a bipartisan way and we will work with all of you, plus everybodyv else in the distribution center to figure out how we can provide
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insulin two diabetics at a cost they can afford. we are going to do that as quickly as we can. as you heard, we're having an ongoing investigation here, we are prepared to talk to youas n and we are prepared to bring it back july or september to talk aboutt the progress we've made. it's not optional it will happen. to thank you all again for coming today and we are not going to have any more testimony but i want to thank you for coming and i want to thank you for being part of the solution and not continuing part of the problem. in closing, ii will remind members that the committee has ten business day to submit questions to the record. i asked the witnesses agree to respond properly to receive any and with that, we are adjourned.
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[inaudible conversations] [inaudible conversations] [inaudible conversations] >> coming up here on c-span2, mexico's minister was in washington d.c. recently on his country's political and financial future and treasury secretary stephen mnuchin the international financial system, he is also releasing trumps tax return. that's today here on c-span2.
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booktv is in prime time this week our congress is on break. we're featuring books on one policy and national security beginning eight eastern with former, security secretary. in her book how safe are we? she talked about dealing with the seven quarter after 11 and concerns about terrorism. >> what we had to protect was the notion that trade and travel still occur, mexico as arizona's feeding trade partner that we couldn't just shield off arizona from snore which is the southern side.
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there was this suspicion that one of the terrorists welcome in through mexico and come into the u.s. that way? we see that kind of fear researching every now and then even to this day. it doesn't happen. >> i'm trying to get a categorization on what that means in the daily life of an arizona people who were there. how does the border see how people live, they are going back and forth. >> let's fast-forward to the recent issues concerning the border with mexico. the notion that it is in crisis and the solution is to build a wall. it's not in crisis and building a wall won't solve anything. the fact of the matter is -- [applause]
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when i was governor of arizona, i would say show me a 10-foot long and i will show you an 11-foot ladder. or a tunnel or something else. the plain fact is, we cannot seal off 1940-mile border, it's a gigantic area. it's a region where a lot of people live, both sides, a region where there's a lot of trade and tourism, families who live on both sides. the border is very diverse geographically, very diverse, private land, public land, indian land, all along the border and so really the border should be thought of more like a zone.
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a zone that requires good management. >> watching time conversation her book, how safe are we? tonight eight eastern. also tonight, how we went. michael on the rise and fall of peace on earth. prudence world spice by amy. it all begins eight eastern here on c-span2. thursday morning, justice department will release a redacted mueller report. once it is replaced, they were about phone lines for your reaction. available, you will be able to find the report on my >> they are stopping at middle and high schools across the country to present the price and went to the winners of our


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